Healthcare Provider Details

I. General information

NPI: 1477542447
Provider Name (Legal Business Name): JAKDEJ NIKOMBORIRAK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 E EDISON AVE
SUNNYSIDE WA
98944-1115
US

IV. Provider business mailing address

PO BOX 719
SUNNYSIDE WA
98944-0719
US

V. Phone/Fax

Practice location:
  • Phone: 509-837-1587
  • Fax:
Mailing address:
  • Phone: 509-837-1617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberMD00036445
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberMD00036445
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: